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APPLICATION FOR WELLIPUMP PERMIT ~ AN JOAQUIN COUNTY PUBLIC HEALTH S .. ENVIRONMENTAL HEALTH DIVISIO RO. BOX 388,904 EAST WEBER AVENUE, KTON, CA 9MI- 88 -- (208) 468.3420 � II NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in TT1pile5t5) APPLICATION IS HERE BY MADE TO THE SAN JOAOVIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDREBSIOR APA# 1705 No Broadway CITY Stockton PARCELSlZVAPN# OWIYER'BNAME William P & George F. Schuler ADDRESS1117 JB'riSt":,ol�Av%e�, Stn SNE,,462-2398 f CONTRACTOR M EX OrQ E�Cn7 AODRES "�[ WLCl11 rte+ ""UCs Sa-�LZ$ PHONE V2z7i--7- 8U6 CONTRACTOR ADDRESS LIC# PHONE r TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL#�Il ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECTREPA R, VAPOR EXTRACTION WELL# J ❑New❑nmoI, H.P. DEPTH PUMP SEI FT. .� FIRST WATER LEVEL O r ❑ OUT-OF-SER�V/1/�fEf�V1�f/yELL7 - ❑ GEOPHYSICAL WELL II •3 ❑ SOIL BORING S . EI IW IT I^�// it •i V �DESTRUCTIQN: a x} it ED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i�l A ' j ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION EA.. OF CONDUCTOR CASING D ' If ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASIMG/STEEUPVChVAV P 00IF NoIV❑ PUBUC/MUNICIPAL ❑DRIVENDEPTH OF GROUT SEAL y4244 tI•ICATION R ❑ IGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY �' GROUT BRAND NAME RRIE ,1 ❑ MONITORING GROUT SEAL PUMPED: ❑Ys ❑No 'I CONCRETE PEDESTAL BY DRILLER:❑Yee ❑Ne S ,} �[ APPROX.DEPTH LOCKING CHESTER BOXMTOVE PPE 5 �. PROPOSED CONSTRUCTIONMRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER 'i i CABLE OTHER I HMBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND f_ REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH k THIS PERMIT 19 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TOW KMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRUNG OR SUB-cONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN TH ANCE OF THE WO FOR WHICH THFS PERMIT IS IBSVEO,F SHALL EMPLOY PERSONS SUBJECT TO WORKMAlI'S COMPENSATION LAWS OF I k CALIFORNIA. ZMNrMUST CA ADV NCE ALL IR WHICH ENSPER:TWNS AT I2O51458j0425• COMPLETE ORAVIRN(i AT LOWER AREA PRO EQ. ( }' k Blared X ntfe Owner '! � Date O'4/ Jy r l PLOT PLAN(Drew to Bash)Soele •to '' t. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. - 4. LOCATKIN OF HOUSE 8EWAOE DISPOSAL$YSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. ,'i EXPANSION OF SEWAGE DISPOSAL SYSTEMS. ' _ 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WEL18 WIFHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS,AND WALKS. ONiTNG HE PROPERTY OR ADJOINIPROPERTY. a, ..,..... ....... ... . ......... ........... .._1-,....-.......,... .....: ........,. .... .................... f .. .....:.. : . y ..... - .. -. - .. .. - ..;.. .. .. .. __ _ R _ - - . - - DEPARTMENT USE ONLY t i - ''''}}�j APPIIaethA Accepted By t }I Dote 04 1 F l __Arae D R++ Grout Irnpeetloo BY Qete Pump Inspection By � Destruction Inspeotlon By 'I'I Dote Commomc ACCOUNTING ONLY: AID# FAC# i PE CODES FEE INFO AMOUNT REMITTED CHECKOMASH RECEIVED BY DATE t# IPERMITISE RVICE REGUES 3 I 37 II h i I� f